Abstract
A 41-year-old woman presented for bridging venoplasty of recurrent superior vena cava (SVC) syndrome as a result of mechanical obstruction from four pacemaker leads (biatrial and biventricular) and an implanted infusion port. She was anticoagulated for atrial arrhythmias and treated with immunosuppressive medications via her port for limited scleroderma and lupus. Periprocedural labs were notable for normal platelet count without coagulopathy. Intravenous heparin was administered for activated clotting time > 200 seconds
Serial venography was performed via left cephalic access, which showed focal narrowing at the SVC-RA (right atrial) junction, as illustrated by the red arrow (Panel A). Peripheral intravascular ultrasound (IVUS; Visions PV 0.35, San Diego, CA, USA), via right femoral access, confirmed severe venous stenosis with fibrotic changes (Panel A). A significant mean gradient was noted on pullback, from 4 mmHg in the right atrium to 9 mmHg in the left brachiocephalic vein. We performed serial dilatations of the lesion, first with a 10 × 40-mm Conquest 40 balloon (Becton Dickenson & Co., NJ, USA), followed by a 12 × 40-mm Armada 35 balloon (Abbott Vascular, CA, USA), and finally a 12 × 40-mm IN.PACT drug-eluting balloon (Impacte Medtronic, CA, USA) for a prolonged 3-minute inflation. The final prolonged inflation resulted in increased mean venous pressure from a baseline 4 mmHg to ~60 mmHg and significant facial flushing and patient discomfort. Repeat venography showed improved flow into the pulmonary arteries with corresponding luminal gain on IVUS (Panel A) as well as an improved mean differential gradient from 5 to 1 mmHg on pullback.
Postprocedure, the patient noted symptomatic improvement but reported new onset facial petechiae, noted by red arrows, which healed spontaneously over 1 week (Panel B: immediately postprocedure [left panels] versus 1 week later [right panels], arrows). This is a phenomenon known as valsalva purpura due to prolonged inflation of our balloon leading to elevated increased thoracic pressure and subsequent extravasations of blood from capillary rupture.1,2 Ultimately, the patient underwent successful surgical SVC reconstruction using a femoral vein panel graft after lead extraction and epicardial lead placement for definitive therapy. The patient gave permission to publish her photographs.
Footnotes
Acknowledgements
Photographs were obtained from the patient with permission for publication.
Declaration of conflicting interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
